Case Studies

ANS Impact – A Drug Utilization Review Case Study

Nancy Jones, a 44 year old female clerk, suffered a compensable industrial injury in May of 2002. At the time of ANS’ intervention, Ms. Jones was taking Brand Valium, Brand Percocet, Fentora, and MS Contin, among other medications. Her total daily medication regime consisted of taking 57 pills per day. Her quality of life was such that she sat in “her chair” throughout the day, watching TV. Ms. Jones had ceased all engagement in her husband’s and children’s lives, essentially living pill to pill. There was no active management of her drug dependency and no expectation of a more positive outcome, based on current medical assessments.

In making the decision to give the case to ANS for pharmacotherapy review, the carrier correctly identified three primary factors that made Ms. Jones’ case a perfect fit for our unique approach.

Inability to settle the claim due to extremely high MSA

High percentage of pharma costs contributing to MSA

Lack of a strategy for a more positive patient outcome.

ANS’PharmIntervention Program

Because of the unique patient centered approach of the ANS PharmIntervention program, Ms. Jones’ insurance carrier felt that ANS might find the solution to improved outcomes and reduced MSA that eludes other “peer to peer” based approaches. With nurse experts in all 50 states it was possible to assign a nurse specialist with local jurisdictional expertise to negotiate face to face with attending physicians, lawyers, and families.This laborious but comprehensive approach allows ANS to achieve and enforce a cost reduced pharma plan that also dramatically improves patient outcomes.

Specifically for Ms. Jones, ANS conducted the following process:

ANS’ legal nurse expert conducted a comprehensive review of Ms. Jones’s medications, medical history, and current quality of life, noting numerous opportunities to not only reduce the excessive costs, but to give Ms. Jones her life back.

Using the results of our comprehensive PharmReview process, a highly trained ANS nurse expert scheduled a face to face meeting with the prescribing physician. Initially, the prescriber was reluctant to schedule the meeting, stating “At the end of every day my voicemail is full of Peer to Peer nonsense”. However, the opportunity to engage in an actual face to face discussion with a person who was clearly familiar with the case, peaked the prescriber’s interest, and he agreed to schedule an appointment.

At the meeting, it was clear the good doctor was expecting a confrontation. What he got instead was a collaborative effort; an honest and frank discussion about Ms. Jones’ pharmaceutical regimen and quality of life from a well-meaning, well prepared Nurse expert who had clearly studied the case. Because the nurse-doctor relationship is not peer based, the discussion is inherently unthreatening, leading easier engagement and buy-in to changes from the attending physician.At the end of this meeting, the ANS nurse expert obtained the doctors signature on the formal Physician Response Form, approving and agreeing to a completely new cost reduced pharma regime and drug treatment plan.

ANS’ Nurse expert then went the further step to meet with Ms. Jones’ attorney for authorization, and actually visited the home of Mrs Jones to discuss the changes to her care. Despite what one might expect, in this meeting Ms. Jones was neither defensive or reluctant to discuss change. Instead Ms. Jones was honest about where she was and who she had become. She saw the process for what it was – a drug treatment intervention, with the opportunity to give her back the life she once had and to restore her dignity

With all 3 phases of the claim involved (the claimant, her attorney, and the prescriber), the prescriber began to implement the agreed to changes. Name brands were converted to generics, dosages were altered, and one by one, a successful weaning effort took place.

ANS’ Nurse expert followed up with the doctor quarterly to discuss progress on, and adherence to the pharma plan. With the relationship developed in their initial meeting, these calls have the tone of concerned colleagues discussing the best possible treatment options for the injured. In the ANS process, it is always the patient at the center of the discussion.

While every WC case is unique and requires expert medical review, they share the problem of having pharma regimes that have spiraled out of control leading to years of suffering for patients, and the waste of millions of dollars. But ANS employ’s a process that relies on a highly personal approach: an approach that takes more time and effort but achieves substantially lower MSA’s and better outcomes than any other provider of drug utilization and Pharmaceutical review services.

The key to success In Ms. Jones’s instance is that unlike every other provider of “Drug Utilization Reviews”, ANS did not stop with a phone call to the prescribing physician. As Ms. Jones’ physician indicated, these calls are often unwelcome and go unanswered. Furthermore they provide neither the quality of review process, or the kind of follow up that achieves a maximum patient result. WC payers leave millions of dollars on the table each year by trusting their drug utilization reviews to a superficial arm’s length analysis,and an inherently flawed “peer to peer” review process.

At the end of the day, Ms. Jones lingering medical conditions are serious. Ms. Jones still takes opioids and other medications, but at a greatly reduced amount. She has not returned to work, but she is “out of her chair” and again able to participate in family life with her husband and 2 children.

For our carrier, the case has been settled. Annual Savings on this case: $87,857.56